Screening Implementation:

Referral and Follow-upWhat Do You Do What Do You Do

When the Screening When the Screening Test Is of Concern?Test Is of Concern?

Paul H. Lipkin, MDPaul H. Lipkin, MDD-PIP Training D-PIP Training

WorkshopWorkshopJune 16, 2006June 16, 2006

I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.

Surveillance And Screening Guidelines: AAP 2006

Perform developmental surveillance at every Perform developmental surveillance at every well-child visitwell-child visit

Perform developmental screening using a Perform developmental screening using a standardized screening tool at 9, 18, and 30* standardized screening tool at 9, 18, and 30* months or when concern is expressedmonths or when concern is expressed

If screening results are concerning, refer If screening results are concerning, refer to developmental and medical evaluations to developmental and medical evaluations and early intervention and early childhood and early intervention and early childhood servicesservices

Follow up on referrals made and Follow up on referrals made and continually track child’s developmental continually track child’s developmental statusstatus

Developmental Screening:Normal Results (AAP 2006)

When the results are When the results are normal:normal:– Inform parents and Inform parents and

continue with other continue with other aspects of the preventive aspects of the preventive visitvisit

– Provides an opportunity Provides an opportunity to focus on to focus on developmental promotiondevelopmental promotion

Developmental Screening:Concerns (AAP 2006)

When administered due to concerns:When administered due to concerns:– Schedule early return visit for additional Schedule early return visit for additional

surveillance, even if the screening tool surveillance, even if the screening tool results do not indicate a risk of delayresults do not indicate a risk of delay

When results concerning, refer for:When results concerning, refer for:– Developmental evaluationsDevelopmental evaluations– Medical evaluationsMedical evaluations– Early developmental intervention/early Early developmental intervention/early

childhood serviceschildhood services

Developmental Evaluation Principles (AAP 2006)

Performed when surveillance or Performed when surveillance or screening identifies a child as being at screening identifies a child as being at high risk of a developmental disorderhigh risk of a developmental disorder

Aimed at identifying the specific Aimed at identifying the specific developmental disorder or disordersdevelopmental disorder or disorders

Provides further prognostic Provides further prognostic informationinformation

Allows prompt initiation of specific Allows prompt initiation of specific and appropriate early childhood and appropriate early childhood therapeutic interventionstherapeutic interventions

Developmental Diagnostic Evaluation

Aimed at identifying the specific Aimed at identifying the specific developmental disorder or disordersdevelopmental disorder or disorders

Performed by any of the following:Performed by any of the following:– Trained and skilled general pediatricianTrained and skilled general pediatrician– Pediatric subspecialistPediatric subspecialist

Neurodevelopmental pediatricians, developmental and Neurodevelopmental pediatricians, developmental and behavioral pediatricians, child neurologists, pediatric behavioral pediatricians, child neurologists, pediatric physiatrists, or child psychiatristsphysiatrists, or child psychiatrists

– Early childhood professionalEarly childhood professional Early childhood educators, child psychologists, speech Early childhood educators, child psychologists, speech

language pathologists, audiologists, social workers, language pathologists, audiologists, social workers, physical therapists, or occupational therapistsphysical therapists, or occupational therapists

– The primary care provider within the medical home should The primary care provider within the medical home should develop an explicit co-management plan with the specialist(s)develop an explicit co-management plan with the specialist(s)

Developmental Diagnostic Evaluation: Identification If a developmental If a developmental

disorder is identified:disorder is identified:– The child should be The child should be

identified as a child with identified as a child with special health care needs special health care needs

Practice registry Practice registry recommendedrecommended

– Chronic condition Chronic condition management should be management should be initiated initiated

Medical Diagnostic Evaluation:

Aim And Components To identify an underlying etiologyTo identify an underlying etiology

– Vision screening and objective hearing Vision screening and objective hearing evaluation evaluation

– Review of newborn metabolic screening Review of newborn metabolic screening and growth charts and growth charts

– Update of environmental, medical, Update of environmental, medical, family, and social history for additional family, and social history for additional risk factors risk factors

– May include brain imaging, May include brain imaging, electroencephalogram (EEG), genetic electroencephalogram (EEG), genetic testing, and/or metabolic testing testing, and/or metabolic testing

May provide parents with a greater May provide parents with a greater depth of understanding of their child’s depth of understanding of their child’s disabilitydisability

Can affect various aspects of treatment Can affect various aspects of treatment planningplanning– Specific prognostic informationSpecific prognostic information– Genetic counseling around recurrence risk Genetic counseling around recurrence risk

and family planningand family planning– Specific medical treatments for improved Specific medical treatments for improved

health and function of the childhealth and function of the child– Therapeutic intervention programmingTherapeutic intervention programming

Medical Diagnostic Evaluation: Other Aims

Medical Diagnostic Evaluation: Etiologic

Investigation Etiology identifiable in Etiology identifiable in

approximately one quarter of cases approximately one quarter of cases of delayed developmentof delayed development – Higher rates (greater than 50%) in Higher rates (greater than 50%) in

children with global developmental children with global developmental delays and motor delaysdelays and motor delays

– Lower rates (less than 5%) in children Lower rates (less than 5%) in children with isolated language disorderswith isolated language disorders

Referral:Early Developmental Intervention/

Early Childhood Services

Often provide evaluation and Often provide evaluation and other services:other services:– Developmental therapiesDevelopmental therapies– Service coordinationService coordination– Social work servicesSocial work services– Assistance with transportation Assistance with transportation

and related costsand related costs– Family trainingFamily training– CounselingCounseling– Home visitsHome visits

Diagnosis not necessary for Diagnosis not necessary for referralreferral

Referral:Early Developmental Intervention/

Early Childhood Services

Settings:Settings:– Specialized health Specialized health

care centers care centers – University centersUniversity centers– Early intervention Early intervention

programsprograms– Early childhood Early childhood

educational educational programsprograms

– Private practices Private practices

Referral Forms: Early Intervention and Local Education

Agency

Office Procedures Document all surveillance, Document all surveillance,

screening, evaluation, and screening, evaluation, and referral activities in the referral activities in the child’s health recordchild’s health record

Coordinate developmental Coordinate developmental and medical evaluations for and medical evaluations for children who have positive children who have positive screening resultsscreening results

IInitiate a program of nitiate a program of chronic condition chronic condition management for child management for child identified with a identified with a developmental disorder developmental disorder

Other Issues: Establish working relationships Establish working relationships

with state and local programs, with state and local programs, services, and resources services, and resources

Utilize a quality-improvement Utilize a quality-improvement model to integrate surveillance model to integrate surveillance and screening into office and screening into office procedures and to monitor their procedures and to monitor their effectiveness and outcomes.effectiveness and outcomes.