Screening Implementation: Referral and Follow-up

1. Screening Implementation: Referral and Follow-up What Do You Do When the Screening Test Is of Concern? Paul H. Lipkin, MD D-PIP Training Workshop June 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.

2. Surveillance And Screening Guidelines: AAP 2006 • Perform developmental surveillance at every well-child visit • Perform developmental screening using a standardized screening tool at 9, 18, and 30* months or when concern is expressed • If screening results are concerning, refer to developmental and medical evaluations and early intervention and early childhood services • Follow up on referrals made and continually track child’s developmental status

4. Developmental Screening:Normal Results (AAP 2006) • When the results are normal: • Inform parents and continue with other aspects of the preventive visit • Provides an opportunity to focus on developmental promotion

5. Developmental Screening:Concerns (AAP 2006) • When administered due to concerns: • Schedule early return visit for additional surveillance, even if the screening tool results do not indicate a risk of delay • When results concerning, refer for: • Developmental evaluations • Medical evaluations • Early developmental intervention/early childhood services

6. Developmental Evaluation Principles (AAP 2006) • Performed when surveillance or screening identifies a child as being at high risk of a developmental disorder • Aimed at identifying the specific developmental disorder or disorders • Provides further prognostic information • Allows prompt initiation of specific and appropriate early childhood therapeutic interventions

7. Developmental Diagnostic Evaluation • Aimed at identifying the specific developmental disorder or disorders • Performed by any of the following: • Trained and skilled general pediatrician • Pediatric subspecialist • Neurodevelopmental pediatricians, developmental and behavioral pediatricians, child neurologists, pediatric physiatrists, or child psychiatrists • Early childhood professional • Early childhood educators, child psychologists, speech language pathologists, audiologists, social workers, physical therapists, or occupational therapists • The primary care provider within the medical home should develop an explicit co-management plan with the specialist(s)

8. Developmental Diagnostic Evaluation: Identification • If a developmental disorder is identified: • The child should be identified as a child with special health care needs • Practice registry recommended • Chronic condition management should be initiated

9. Medical Diagnostic Evaluation:Aim And Components • To identify an underlying etiology • Vision screening and objective hearing evaluation • Review of newborn metabolic screening and growth charts • Update of environmental, medical, family, and social history for additional risk factors • May include brain imaging, electroencephalogram (EEG), genetic testing, and/or metabolic testing

10. Medical Diagnostic Evaluation: Other Aims • May provide parents with a greater depth of understanding of their child’s disability • Can affect various aspects of treatment planning • Specific prognostic information • Genetic counseling around recurrence risk and family planning • Specific medical treatments for improved health and function of the child • Therapeutic intervention programming

11. Medical Diagnostic Evaluation: Etiologic Investigation • Etiology identifiable in approximately one quarter of cases of delayed development • Higher rates (greater than 50%) in children with global developmental delays and motor delays • Lower rates (less than 5%) in children with isolated language disorders

12. Referral:Early Developmental Intervention/Early Childhood Services • Often provide evaluation and other services: • Developmental therapies • Service coordination • Social work services • Assistance with transportation and related costs • Family training • Counseling • Home visits • Diagnosis not necessary for referral

13. Referral:Early Developmental Intervention/Early Childhood Services • Settings: • Specialized health care centers • University centers • Early intervention programs • Early childhood educational programs • Private practices

14. Referral Forms: Early Intervention and Local Education Agency

15. Office Procedures • Document all surveillance, screening, evaluation, and referral activities in the child’s health record • Coordinate developmental and medical evaluations for children who have positive screening results • Initiate a program of chronic condition management for child identified with a developmental disorder

16. Other Issues: • Establish working relationships with state and local programs, services, and resources • Utilize a quality-improvement model to integrate surveillance and screening into office procedures and to monitor their effectiveness and outcomes.