Developmental Screening

Importance of Developmental Screening

In the United States, about 1:8 children (13%) have a developmental or behavioral disability. [Boulet: 2009] Opportunities for early intervention are lost or significantly delayed if children with developmental disabilities are not identified early on. Developmental screening programs result in increased detection of developmental delays. [Bagner: 2014] [Adams: 2013] In addition, Title V of the Social Security Act and the Individuals with Disabilities Education Improvement Act (IDEIA) mandate that clinicians provide these services.

Surveillance vs. Screening

Developmental Surveillance
Developmental surveillance, also known also as developmental monitoring, is a flexible, longitudinal, continuous, and cumulative process that should be included at each pediatric preventive care visit throughout the first 5 years of life. [American: 2014] If concerns arise as a result of developmental surveillance, a developmental screening tool should be administered or, when there is sufficient concern, further evaluation should be undertaken for specific developmental disabilities.
Developmental Screening
Screening is the administration of a brief standardized tool to help identify children at risk of a developmental disability. It is administered in the medical home or by trained providers and teachers in some day cares or early learning centers. Concerning results from the screen should trigger further evaluation for specific developmental disabilities.
Child demonstating developmental milestone by drawing
Photo by Jake Guild
Screening provides greater sensitivity (correctly identifying children who are at risk for a developmental delay) and specificity (correctly avoiding positive screen results in children who do not have a developmental delay) than surveillance.

Using developmental checklists can help with monitoring, but does not take the place of using validated developmental screening instruments.
Screening and Surveillance Process Overview
Screening involves:
  • Using a validated screening tool.
  • Identifying children at increased risk of a
    developmental delay who should
    be referred for further developmental or
    medical evaluation and intervention.
Surveillance involves:
  • Listening to concerns of caregivers
  • Obtaining and maintaining a developmental history
  • Observing the child during visits
  • Identifying risks and protective factors
  • Documenting findings

When to Screen

Developmental screening of ALL children is recommended at the 9-, 18-, and 24- or 30-month, well-child visits. [American: 2014] Repeated developmental screening provides a more accurate assessment of development than a single evaluation and allows for monitoring of developmental progression (or regression) over time. Additional screening may be beneficial in children with a history of prematurity, low birth weight, or other unique circumstances. [American: 2014]

Screening Tools

The developmental screens listed below are:
  • Validated for a primary care population for screening use at the 9-, 18- and 30- (or 24-) month visits
  • Broadband instruments that screen multiple domains of development, including some combination of gross and fine motor, language/communication, cognitive, academic, self-help, problem-solving, social-emotional, and behavioral skills
  • Vetted for favorable psychometric properties, defined as sensitivity and specificity of at least 70%, and reliable, consistent results when used in different settings
  • Parent-completed questionnaire (screens requiring a trained observer to complete the questionnaire are not included here)
  • Administered in 15 minutes or less
  • Compatible with electronic medical records
  • Available in multiple languages
A variety of tools provide flexible options for use in the primary care setting. For a detailed overview of developmental screening instruments and how to choose one for your practice, see Birth to 5: Watch Me Thrive (HHS) (PDF Document 1007 KB).

Ages & Stages Questionnaires, 3rd edition (ASQ-3)

  • Format: 21 questionnaires that are age specific, 30 items per questionnaire
  • Age range: 1 - 66 months
  • Scoring: cut off points for each domain that indicate recommendation for further monitoring or referral
  • Parent reading level: 4th - 6th grade
  • Languages: English, Spanish, French. An online system can be purchased for use in English, Spanish, Somali, and Hmong.
  • Can be supplemented with concurrent use of Ages and Stages Questionnaire: Social-Emotional (ASQ:SE-2) (Brookes)
Available for purchase at Ages and Stages Questionnaire: Developmental (ASQ-3) (Brookes).

Parents Evaluation of Developmental Status (PEDS)

  • Format: single parental response form, 10 items per questionnaire
  • Age range: birth to 7 years 11 months
  • Scoring: algorithm that indicates need for referral, further screening, or continued surveillance
  • Parent reading level: 4th - 5th grade
  • Languages: English, Spanish, Vietnamese. Licensed translations also available in Albanian, Amharic, Arabic, Armenian, Bengali, Bulgarian, Burmese, Cambodian, Chinese (Traditional and Simplified characters), Danish, Dutch, Dzongkha, Farsi, Filipino Tagalog, French, Galician, German, Greek, Gujarati, Haitian-Creole, Hebrew, Hindi, Hmong, Icelandic, Indonesian, Karen, Korean, Laotian, Malay, Nepali, Polish, Portuguese and Cape Verdean, Punjabi, Russian, Serbian (Cyrillic and Latin), Somali, Swahili, Tagalog, Taiwanese, Thai, Turkish, Urdu, Visayan, and Yoruba
  • May also be useful as a surveillance tool
  • Can be supplemented with concurrent use of Parents’ Evaluation of Developmental Status: Developmental Milestones (PEDS:DM)

Parents Evaluation of Developmental Status: Developmental Milestones (PEDS:DM)

  • Format: different age-specific questionnaires, 6 to 8 items per questionnaire
  • Age range: birth to 7 years 11 months
  • Scoring: pass/no pass for each of the tested domains
  • Parent reading level: 4th - 5th grade
  • Languages: English and some forms available in Spanish
  • Can be supplemented with concurrent use of Parents’ Evaluation of Developmental Status (PEDS)

Survey of Well-Being of Young Children (SWYC)

  • Format: set of age-specific tools usually completed in less than 10 minutes, which include:
    • Baby Pediatric Symptom Checklist (BPSC): 18-item screen for social-emotional development from birth to 18 months. The SWYC/MA version adds postpartum depression screening to the early infancy visits.
    • Preschool Pediatric Symptom Checklist (PPSC): 25-item screen for social-emotional development from 18-60 months
    • Parent’s Observations of Social Interactions (POSI): autism screen for 16-30 month olds; questions are integrated into the 18-, 24-, and 30-month screens
    • Family Risk Factors: questions assembled from other previously validated instruments to screen caregivers for substance abuse, parental depression, inadequate food supply, and domestic violence
    • The Developmental Milestones Checklists: Various 10-item, age-specific screens for language, fine and gross motor skills, and cognitive development. The overall sensitivity for the milestones portion was 76% and specificity was 77%.
  • Age range: age specific from 1 month to 5 years 6 months
  • Scoring: different scoring algorithms for each component. Scoring can be done in Excel or manually, or via the electronic medical record in an integrated eSWYC system. Developmental Milestones are pass/no pass (or “needs review”).
  • Parent reading level: 6th grade
  • Languages: English, Spanish, Burmese, Nepali, and Portuguese with additional languages undergoing validation.
  • Some clinical practices use the entire set of tools at every well child check-up, whereas other practices use only 1 component of the set of screens, such as using only the Developmental Milestones.
On-line versions are available for no charge at The Survey of Well-Being of Young Children (Tufts Medical Center). Electronic systems that can be integrated with electronic medical record are in development (some are already available).

Pearls and Alerts

  • Be aware that each screening tool carries its own sets of strengths and limitations.
  • When choosing a screening tool for your practice, consider cost, implementation, language and literacy barriers, and privacy issues for family members filling out information.
  • Some questions may not be as relevant in certain cultures or for children living in foster families or in group care settings.
  • Recognize that these tools may not be validated for children from bilingual or multilingual homes, or in children who have complex medical conditions or disabilities.
  • Remember to correct for prematurity in children under 24 months.
  • Be prepared to answer questions about typical vs. atypical development and to provide appropriate support and referrals.
  • Use of developmental milestone trackers at each check-up can be useful for monitoring and to engage families, but it does not take the place of formal, validated screening instruments.
  • Diagnosis of a specific developmental disability is NOT necessary for an early intervention program (EIP) referral to be made or for services to begin.

Response to a Positive Screen

Primary Care

A positive screening test may cause considerable anxiety for the parents, so it is important to help them understand that a concerning developmental screen does not always indicate an abnormality, nor does it provide a diagnosis or treatment plan. Rather, it identifies areas in which a child’s development differs from same-age norms. If results are concerning, the child should be referred to an early intervention program or to their school district for testing for school-based services and scheduled for a comprehensive developmental evaluation.

Specialty Care

A comprehensive evaluation or definitive diagnosis is not necessary for intervention to begin. Referral to a program that can both assist in the evaluation and provide services to help the child and parents is recommended when there is concern about developmental delay:
  • Early intervention programs (see all Early Intervention for Children with Disabilities/Delays services providers (207) in our database): Families may self-refer to early intervention, but the clinician may send a referral form to provide specific information and to better coordinate care. The program may provide services such as developmental therapies, service coordination, family training, counseling, and home visits. The program will NOT perform a medical evaluation or other evaluations to establish a diagnosis of a specific developmental disability
The evaluation of a child for developmental delay may involve some or all of the specialists and disciplines noted below, depending on the specific findings at each stage of evaluation. Some communities will have a multi-disciplinary developmental clinic where all of the needed services will be available. If there are no such clinics nearby, the medical home may identify individual providers of the various components. The goal of a comprehensive evaluation is to identify a specific developmental disability to aid in developing an appropriate treatment plan and to offer a prognosis for the child.

Subspecialist Collaborations

  • Audiologist (see all Audiology services providers (328) in our database): Evaluates for hearing loss as a potential cause or contributor to developmental delay.
  • Geneticist and genetic counselor (we currently have no Pediatric Genetics service providers listed, please search our Services database for related services and see all Pediatric Genetic Counseling services providers (41) in our database: Performs evaluation when an underlying medical condition or genetic syndrome is suggested by family history, examination, or clinical course.
  • Licensed social worker (see all Social Workers services providers (66) in our database): Identifies family needs and refers family to formal and informal support agencies and organizations (some social workers provide direct counseling and therapy).
  • Occupational therapist see all Occupational Therapy, Pediatric services providers (76) in our database: Evaluates for self-help and self-care deficits and sensory processing deficits. Develops a plan for treatment to optimize function and participation in daily tasks and activities (some also work on feeding problems).
  • Pediatric neurologist (see all Pediatric Neurology services providers (10) in our database): Evaluates for underlying neurological and neuromuscular disorders, develops treatment plan.
  • Physical medicine and rehabilitation physician (see all Pediatric Physical Medicine & Rehab services providers (5) in our database): Evaluates physical function and movement, develops medical and rehabilitation treatment plan for children with brain or spinal cord injuries, neuromuscular disorders, and other musculoskeletal conditions.
  • Physical therapist (see all Physical Therapy services providers (384) in our database): Evaluates physical function and movement. Develops a plan for treatment including physical activities and adaptive equipment to optimize function.
  • Primary care clinician or developmental pediatrician (see all Developmental Pediatrics services providers (1) in our database): Performs medical evaluation; identifies and treats associated conditions.
  • Psychiatrist (see all Psychiatrist, Child-18 (MD) services providers (24) in our database): Evaluates and treats associated psychiatric conditions and maladaptive behaviors.
  • Psychologist (see all Psychologist, Child-18 (PhD, PsyD) services providers (7) in our database): Administers cognitive or developmental testing or other diagnostic tools. Identifies associated psychiatric conditions and develops behavioral treatment plan.
  • Speech-language pathologist (see all Speech Therapy services providers (416) in our database): Evaluates for expressive, receptive, and pragmatic language deficits; develops a plan for treatment (some also work on feeding problems).

Resources

Information & Support

For Professionals

Birth to 5: Watch Me Thrive (HHS) (PDF Document 1007 KB)
A compendium of developmental screening measures for young children and information about the reliability and validity of commonly-used developmental screening tools; U.S. Department of Health and Human Services, 2014.

For Health Care Providers: Learn the Signs. Act Early. (CDC)
Links to a comparison table of validated screening tools and a Health Care Provider Primer; an audio presentation about free tools offered by this program; and other free, developmental screening resources; Centers for Disease Control and Prevention.

Early Intervention Contacts (CDC)
Contact information by state; Centers for Disease Control and Prevention.

Developmental Red Flags (Kids Get Care) (PDF Document 186 KB)
A printable developmental surveillance checklist that gives tips for finding possible developmental delays; not a validated screening instrument.

For Parents and Patients

Support

Family Voices
A national, nonprofit, family-led organization promoting quality health care for all children and youth, particularly those with special health care needs. Locate centers by state, F2F HICs (Family-to-Family Health Information Centers).

Help Me Grow
A national organization of state programs focused on screening young children for developmental and behavioral problems and connecting their families with services.

General

Learn the Signs. Act Early (CDC)
Tools, videos, lists, and learning materials to track a child’s development (ages 2 months to 5 years) and act if concerned about progress; Centers for Disease Control and Prevention.

Positive Parenting Tips: Babies, Toddlers & Preschoolers (CDC) (PDF Document 137 KB)
How to nurture, protect, and guide your child through different life stages; Centers for Disease Control & Prevention.

Early Intervention: What It Is and How It Works (understood.org)
General explanation about the purpose of early intervention and what types of services are available through early intervention programs around the country.

Tools and Materials for Tracking Milestones (CDC)
Milestone tracker apps, parent kits, videos, photos, books and tip sheets for tracking developmental milestones; Centers for Disease Control and Prevention.

Early Intervention Contact Information by State (CDC)
Phone numbers and links to websites of early intervention programs in each state, commonwealth, and territory; Centers for Disease Control and Prevention.

Physical Developmental Delays (healthychildren.org)
Checklists that are organized by age and activity, which have some illustrations and videos of how to monitor your child for motor delays; from the American Academy of Pediatrics.

Parenting (Zero to Three)
Resources to support families and communities in the care of young children; includes FAQs, parenting tips, and educational handouts about behavior, sleep, play, language, and more.

Parents' Guide to Understanding Pediatric Specialists (healthychildren.org)
Learn more about pediatric medical subspecialists and their role in care of your child; from the American Academy of Pediatrics.

Developmental Milestones (pathways.org)
Developmental milestones for 0-3 years.

Practice Guidelines

American Academy of Pediatrics.
Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening.
Pediatrics (original publication 2006; reaffirmed 2014). 2014;118(1):405-20. PubMed abstract / Full Text

Tools

Ages and Stages Questionnaire: Developmental (ASQ-3) (Brookes)
Parent-completed, age-specific questionnaires that screen for developmental delays in children between 1 month and 5½ years old; available for purchase.

Ages and Stages Questionnaire: Social-Emotional (ASQ:SE-2) (Brookes)
A parent-completed series of 19 age-specific questionnaires screening communication, gross motor, fine motor, problem-solving, and personal adaptive skills. Results are in a pass/fail format for domains; available for purchase.

Parents Evaluation of Developmental Status (PEDS and PEDS:DM)
Parent-completed age-specific questionnaires used for children 0 months to 7 years old. Includes an algorithm that indicates need for referral, further screening, or continued surveillance (PEDS:DM). Parent reading level: 4th to 5th grade. Available for purchase in many languages.

The Survey of Well-Being of Young Children (Tufts Medical Center)
Free, 10-minute screening tools encompassing behavioral, developmental, social-emotional, autism, and family well-being for well-child visits ages 2 months to 5 ½ years.

Services

Audiology

See all Audiology services providers (328) in our database.

Developmental Pediatrics

See all Developmental Pediatrics services providers (1) in our database.

Early Intervention for Children with Disabilities/Delays

See all Early Intervention for Children with Disabilities/Delays services providers (207) in our database.

Head Start/Early Head Start

See all Head Start/Early Head Start services providers (132) in our database.

Occupational Therapy, Pediatric

See all Occupational Therapy, Pediatric services providers (76) in our database.

Pediatric Genetic Counseling

See all Pediatric Genetic Counseling services providers (41) in our database.

Pediatric Genetics

We currently have no Pediatric Genetics service providers listed; search our Services database for related services.

Pediatric Neurology

See all Pediatric Neurology services providers (10) in our database.

Pediatric Physical Medicine & Rehab

See all Pediatric Physical Medicine & Rehab services providers (5) in our database.

Physical Therapy

See all Physical Therapy services providers (384) in our database.

Psychiatrist, Child-18 (MD)

See all Psychiatrist, Child-18 (MD) services providers (24) in our database.

Psychologist, Child-18 (PhD, PsyD)

See all Psychologist, Child-18 (PhD, PsyD) services providers (7) in our database.

Social Workers

See all Social Workers services providers (66) in our database.

Speech Therapy

See all Speech Therapy services providers (416) in our database.

For other services related to this condition, browse our Services categories or search our database.

Authors

Lead Author: Jennifer Goldman-Luthy, MD, MRP, FAAP - 10/2017
Author: Sarah Winter, MD - 2/2011
Reviewing Author: Paul Carbone, MD - 2/2011

Page Bibliography

Adams RC, Tapia C.
Early intervention, IDEA Part C services, and the medical home: collaboration for best practice and best outcomes.
Pediatrics. 2013;132(4):e1073-88. PubMed abstract / Full Text
Published in 2013 and reaffirmed in August 2017, this clinical report provides information for primary care providers about early intervention services and optimal partnership and referrals.

American Academy of Pediatrics.
Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening.
Pediatrics (original publication 2006; reaffirmed 2014). 2014;118(1):405-20. PubMed abstract / Full Text

Bagner DM, Frazier SL, Berkovits M.
Getting ready for preschool: linking early intervention and family mental health for infants and toddlers with developmental delay.
Adm Policy Ment Health. 2014;41(6):707-11. PubMed abstract / Full Text

Boulet SL, Boyle CA, Schieve LA.
Health care use and health and functional impact of developmental disabilities among US children, 1997-2005.
Arch Pediatr Adolesc Med. 2009;163(1):19-26. PubMed abstract