Developmental Screening

Learning disabilities, language delays, mental retardation, and social-emotional problems affect up to 18% of children. Less than 1/3 of these children with disabilities are identified before they begin school, delaying appropriate and helpful interventions. Low enrollment rates, at about 80%, in early intervention programs indicate the need for primary care providers to improve screening services to identify these children. Early intervention programs can help improve long-term outcomes including improving the likelihood of graduating from school and avoiding teenage pregnancy. [www.dbpeds.org Tutorials]

Improving developmental screening requires the use of standardized screening tools rather than relying on identifying possible delays from parent's questions or clinical observations during a busy well- or sick-child visit. While some experts recommend implementing developmental screening at every well-child visit, choosing key visits at critical ages can be a way to introduce standardized screening with manageable changes to office procedures. Additionally, screening tools should be used when parents or providers have concerns about appropriate development. [www.dbpeds.org Tutorials] [American: 2006]

The pediatrician is the best-informed professional with whom many families have contact during the first 5 years of a child's life. Parents look to the pediatrician to be the expert not only on childhood illnesses but also on child development. [Committee: 2001]

Some content on this page adapted with permission from the Washington State Medical Home Project, Katherine TeKolste, MD. FAAP. Developmental Pediatrician, MHLN Medical Consultant and Sam Zinner, MD, FAAP, Developmental Pediatrician.

Well child visits present opportunities to:

1. Listen to the parents;
2. Observe the parent-child relationship;
3. Provide support and information on child development;
4. Assess risk factors;
5. Monitor development using screening tools and surveillance;
6. Make a referral, when necessary, to an early intervention program;
7. Guide parents, when delay is uncertain or not yet confirmed;

• Listen to the parents.
  Listen to concerns and avoid the "Don't worry, (s)he'll grow out of it" trap. When a parent expresses concern about a child's development, there is a good chance there is something that needs attention. A regular topic for discussion by parents in parent groups in early intervention programs is the feeling that health care providers do not value their concerns. "I felt like I was dismissed when I mentioned that I was concerned that my baby wasn't crawling and that he hated being on his tummy," confided a mom whose child was identified as having a motor and language delay through a community screening. Parental concerns are particularly likely to be accurate in the areas of speech and language skills, cognitive performance, and fine motor skills. It is also important to recognize that 20-25% of parents do not raise concerns when delays are present.
• Observe the parent-child relationship and how the parent:
  • comforts the child;
  • accepts the child's feelings;
  • is or is not intrusive;
  • allows independence;
  • shows positive feelings; and
  • responds to the child's cues.
  Concerns in this area might be a prompt for further screening to detect social-emotional delays in the infant or maternal depression in the mother that may be affecting the relationship. For additional information, see the following page(s): Screening>>Infant Social-Emotional Screening; or Screening>>Maternal Depression Screening.
• Provide support and information on child development. Downloadable handouts are available at Early Developmental Guide for Parents and Parenting Children Aged Zero to Three. Also see Web Resources for Parents.
• Assess risk factors. Biologic and environmental factors may place a child at higher risk for poor outcome. Children and families for whom these risk factors are present should be monitored closely. A child with an established diagnosis associated with a high likelihood of developmental delay (e.g. autism) should be referred for early intervention services promptly upon diagnosis. See the list of "Diagnoses or conditions associated with developmental delays". Also see Resources on this page for suggested referral forms.
• Monitor development using screening and surveillance. See Tools on this page for a short list of suggested screening tools.
  • Screening
    • Typical development varies with every child, but generally follows predictable patterns that can be assessed in a variety of ways. Screening involves assessment of some aspects of development that have been shown to be representative of normal developmental progress at certain ages. "Failing" a screening test does not necessarily mean the child is developmentally abnormal, but should trigger further evaluation, depending on the type and degree of "failure".
    • Because most pediatricians have been informally trained in using the Denver II, developed by Dr. William Frankenburg at the University of Colorado Health Sciences Center, they often rely on it to validate their suspicions about their patients' development. The Denver is a "hands on" screening tool that also allows for parental report for some items. Unfortunately, because of time constraints, the 20 minutes needed to reliably administer the tool is not always taken.
    • Development is progressive and high quality screening strategies involve periodic evaluation of each child at various stages of development, using tools appropriate for their age. The AAP recommends screening at each well-child visit. See Tools on this page for examples of tools that may be used for screening.
  • Surveillance
    • Developmental surveillance is an informal, yet structured monitoring of developmental status over time. The primary care provider must interpret information in light of environmental, social and medical factors affecting the child. Developmental surveillance relies upon information obtained from multiple sources, including assessment of parental concerns and formal developmental screening. Although they should not be the primary method of assessing development, checklists with red flags in development may be useful (see Developmental Red Flags), especially at interim visits when formal developmental screening is not utilized.

Diagnoses or conditions associated with developmental delays: (This list is not all-inclusive.)

1. Chromosomal/Genetic
   1. Trisomies, Translocation, deletions
      1. Down Syndrome
      2. Williams Syndrome
      3. Cri-du-chat
      4. All unbalanced structural chromosome syndrome
      5. Prader-Willi Syndrome
      6. Klinefelter Syndrome
      7. Angelman Syndrome
      8. Velo-cardio-facial or DiGeorge Syndrome
   2. Sex-linked
      1. Fragile X Syndrome
      2. Lowe Syndrome
      3. FG Syndrome
2. Syndromal
   1. Cockayne Syndrome
   2. Bardet-Biedl Syndrome
   3. Cornelia de Lange Syndrome
   4. Rubenstein-Taybi Syndrome
3. Neuromuscular Disorders
   1. Cerebral Palsy
   2. Muscular Dystrophy
      1. Duchenne Type
      2. Becker Type
   3. Myopathies
   4. Anterior Horn Cell Disorders
      1. Werdnig-Hoffman Syndrome
      2. Kugelburg-Wehlander Syndrome
4. Neurocutaneous Disorders
   1. Sturge-Weber
   2. Tuberous Sclerosis
   3. Neurofibromatosis Type 1
5. Spinal Cord Injury with Cord Involvement
6. Musculoskeletal Diseases
   1. Arthrogryposis
   2. Reduction Deformity
7. Central Nervous System
   1. Congenital Brain Malformation
   2. Encephalocele
   3. Spina Bifida
   4. Hypoxic Ischemic Encephalopathy with seizures
8. Orofacial Abnormalities
   1. Treacher Collins
   2. Pierre-Robin Sequence
   3. Moebius Sequence
   4. Warrdenburg Syndrome, Types I and II
9. Pervasive Developmental Delay
10. Autistic Spectrum Disorders
11. Sensory Loss
    1. Vision (List of specific disorders available upon request)
    2. Hearing (List of specific disorders available upon request)
    3. Deafblind
12. Abnormalities of Metabolism
    1. Amino Acid
       1. Maple Syrup Urine Disease
       2. Untreated PKU
    2. Carbohydrate
       1. Infantile Gaucher Disease
       2. Methylmalonic acidemia
    3. Lipid
       1. Niemann-Pick Disease
       2. Tay-Sachs Disease
    4. Purine/Pyrimidine
       1. Lesch-Nyhan Syndrome
    5. Thyroid
       1. Untreated Hypothyroidism
    6. Mucopolysaccharidosis
       1. Hunter Syndrome
       2. Hurler Syndrome
       3. Scheie Syndrome
       4. Sanfilippo Syndrome
       5. Sly Syndrome
13. Ventilator Dependent
14. Congenital Infections
    1. Cytomegalovirus
    2. Herpes
    3. HIV
    4. Rubella
    5. Syphilis
    6. Toxoplasmosis
15. Failure to Thrive
16. Environmental Agents
    1. Fetal Alcohol Syndrome
    2. Fetal Valproate Syndrome
    3. Fetal Hydantoin Syndrome
17. NICU Graduate with one or more of the following conditions:
    1. NG or G tube feedings required either full or partial to maintain adequate nutrition
    2. Unable to take 100% of nutrition by mouth
    3. Difficulty pacing and/or coordinating suck-swallow-breathe, especially if 38-40 weeks or older
    4. Long, difficult time to learn to eat
    5. Unusually high tone
    6. Significant tremors when at rest
    7. Tone: such as, low tone when resting and high tone when over stimulated
    8. Inconsolability not attributable to typical premature irritability, GER, or other medical conditions
    9. Neurologically based significant irritability
    10. Unable to come to a quiet-alert state, persisting throughout hospitalization
    11. Severe sleep disorder, e.g. unable to maintain deep sleep for 2 hours or more

Other Names

Checking developmental milestones

Early Signs

While each child develops differently, some signs may indicate the need for screening including when the child:

• does not respond to his or her name;
• does not make eye contact with his or her parents';
• does not smile and make laughing noises;
• does not develop language skills similar to peers;
• does not communicate when something is wrong or when help is needed;
• does not have appropriate body posture or tone for age; or
• uses repetitive motions with body or limbs.

ICD-9

783.4, Lack of expected normal physiological development in childhood

V20.2, Routine infant or child health check

V70.0, Routine general medical examination at a health care facility

V79.3, Screening for developmental handicaps in early childhood

V79.8, Screening for other specified mental disorders and developmental handicaps

V79.9, Screening for unspecified mental disorder and developmental handicap

The listed ICD-9 and V codes may be used for screening. The list does not include codes for diagnosed conditions.

CPT

96110, Developmental Screening

96111, Developmental Testing

In 2003, "two codes specifically relating to 'developmental and behavioral' pediatrics were approved by CMS and thereby setting the path for reimbursement for the services these codes cover." [www.dbpeds.org]

"Billing code 96110 covers a physician or non-physician administering a standardized screening instrument (broadband or autism-specific) to a child's guardian or other observer, and reflects only the physician time reviewing the scores and interpreting the findings with the family (rather than the actual work of giving the survey). Using this code requires documentation that the screen was given and the actions taken." [www.developmentalscreening.org]

"When adding the 96110 screening code to an evaluation and management visit, American Medical Association CPT (Current Procedural Terminology) codes guide providers to append the modifier "-25" to the E/M code. Given that the evaluation is a significant, separate service from the screening procedure, it's acceptable to bill 96110 for every screening tool used. However, individual payers may contract with participating providers to include the screen within preventive care or E/M, or may direct their providers to bill differently from the AMA's CPT guidelines." [www.developmentalscreening.org]

Guidelines

Tools

Response to a Positive Screen

Resources

Authors

Page Bibliography

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;118(1):405-20. PubMed abstract / Full Text

American Academy of Pediatrics.
Recommendations for preventive pediatric health care.
Pediatrics. 2007;120(6):1376. PubMed abstract / Full Text

Committee on Children with Disabilties.
Developmental surveillance and screening of infants and young children.
Pediatrics. 2001;108(1):192-6. PubMed abstract / Full Text
This article encourages physicians to use standardized developmental screening tools and suggests that testing children at periodic intervals will increase accuracy and further early intervention.

Rydz D, Srour M, Oskoui M, Marget N, Shiller M, Birnbaum R, Majnemer A, Shevell MI.
Screening for developmental delay in the setting of a community pediatric clinic: a prospective assessment of parent-report questionnaires.
Pediatrics. 2006;118(4):e1178-86. PubMed abstract / Full Text