The following screening guidelines for children under 36 months outline a seven-step
process for healthcrae providers to use when monitoring healthy development1:
1. Make clinical observations and chart developmental milestones
Conduct routine developmental screening and surveillance
If concerns are raised:
3. Refer to Early Intervention AND to specialist for further developmental
4. Conduct lead screening
5. Perform formal audiological assessment
6. Conduct autism screening.
If additional concerns are raised:
7. Refer for formal diagnostic
The first three years of life
are crucial to a child’s development. During this
period of early development, children make regular visits to the physician. Well
visits provide important opportunities to record history, observe the child,
and monitor the child’s developmental progress over time. First Signs has outlined a
seven-step process. The following guidelines, adapted from key policy statements
of the American Academy of Pediatrics and American Academy of Neurology (Practice
Parameter)1 , were developed in order to establish standard
practices amongst physicians, to simplify the screening process, and to ensure
that all children receive routine and appropriate screenings and timely
These recommended guidelines are critical to ensuring that young children stay
on a healthy developmental path.
1. General observations
and developmental milestones. First Signs
recommends that physicians take a brief moment at the start of each well visit
to observe how the child behaves, interacts, and communicates with a parent or
caregiver in either the reception area or examining room. Use the developmental
milestone to refer to the social,
emotional, and communication milestones for a child’s age and discuss the child’s
development with the child’s parents or caregivers. Since it is often difficult
to pick up the subtleties of atypical development in a busy practice, measurement
through a highly validated developmental screening tool is recommended as the most efficient and
effective way to monitor a child’s development.
Routine developmental screening. First Signs
recommends that a physician, nurse practitioner, or certified
physician assistant perform routine developmental screenings using a
highly validated screening tool at each well visit on all children
from birth through school age to identify those at risk for atypical
development. A screening can give physicians the opportunity to
share a child’s developmental strengths and challenges with parents
and work with the family to get that child on the correct
developmental path. There are a variety of ways that practitioners
can integrate a developmental screening into a well visit. A parent
can complete the screening form in the physician’s waiting room, at
home before a well visit, or with the assistance of a nurse,
physician, or other professional in the examination room in less
than 10 minutes.
All screening tools vary with respect to targeted age range,
accuracy, ease of use, completion time, languages available, and
cost. Some developmental screening tools are more specific to social
and communication milestones, and some are more specific to gross
and fine motor skills, while others are more specific to behavior
and temperament. All screening tools have limitations and should not
take the place of good clinical history and observations.
Conversely, clinical history and observations should not take the
place of a good screening. Whenever developmental screenings produce
concerns, it is essential that physicians refer children for further
evaluation, whether or not their own clinical observations agree
with the outcome.
There are several validated screening tools that can be used for routine developmental
Screening Tools for more information. There, you will find
supporting data, including validity and standardization norms, references to
peer-reviewed publications, information about ease of use for clinicians and
parents, languages available, and costs2.
If concerns are raised:
Refer to Early Intervention and to specialist for further developmental
evaluation. When a developmental screening indicates a
possible delay, First Signs recommends that you refer the
child to Early Intervention
and directly to a specialist (i.e., developmental pediatrician,
pediatric neurologist, psychiatrist, or psychologist) for further
developmental evaluation. (See the PDF version of the First Signs
brochure “A Pediatric Practitioner's Guide: Referring a Child to Early Intervention” a)
outside panels, b)
Lead screening. Developmental delays and behavioral problems
can be a sign of lead poisoning. A child who mouths many objects, or
puts non-food items in the mouth, may be at risk for lead poisoning.
Because of the range of risks involved, lead screenings are
performed routinely when a child shows signs of a developmental
delay or disorder. First Signs recommends that this screening be
conducted immediately to rule out lead poisoning and, if detected,
to minimize the negative effects of lead exposure. If elevated lead
levels are found, refer the child to a local health department.
Additionally, you may want to refer the child for other medical
screenings or sub-specialty evaluations to rule out other
conditions, since other factors can contribute to high lead levels.
Formal audiological assessment. The relationship between a child’s
hearing, communication, and overall development is complex: a child who appears
to have a developmental delay may, in fact, have a hearing impairment. A child
with a hearing impairment that goes undiagnosed may experience resulting delays
in development and communication. A child with a communication or developmental
disorder may also have related issues with sensitivity to sound. When addressing
concerns about a child, First Signs recommends that a developmental screening be followed by formal audiological testing.
Autism screening. If a routine developmental screening raises concerns,
recommends that you automatically follow up with an autism
screening. A parent can complete the autism screening
form in the physician’s waiting room or with the assistance of a nurse, physician,
or other professional in the examination room in less than five minutes.
Most autism screening tools are designed to detect autism spectrum disorder,
concentrating on social and communication impairment in children and focusing
on diagnostic criteria for ASD. They all vary with respect to validated age at
which the tool should be administered, accuracy, and languages available. All
autism screening tools have limitations, most notably in the lack of well-validated
screening tools available for children 18 months of age and younger.
for more information, including supporting data such as validity and
standardization norms, references to peer reviewed publications,
information on ease of use for both health care providers and
caregivers, languages available, and costs.2
If additional concerns are raised:
Formal diagnostic evaluation. If an autism screening raises
concerns—or for a child 18 months and younger, there are concerns
raised from the history and observations—First Signs
recommends that you refer the child to a developmental pediatrician,
pediatric neurologist, psychiatrist, psychologist, or an autism
specialty team for a formal diagnostic evaluation right away. This
clinician should specialize in evaluating children with autism
These recommended guidelines are critical for ensuring that young children stay
on a healthy development path. Pediatric practitioners play an
important role in guiding children and families to favorable developmental outcomes.
1 Screening Guidelines were compiled and adapted from the following sources:
American Academy of Pediatrics. (2001). Committee on Children
with Disabilities. Policy Statement: The pediatrician’s role in
the diagnosis and management of autistic spectrum disorders in
children, Pediatrics, 107, 1221-1226; American Academy of
Pediatrics. (2001). Committee on Children with Disabilities.
Technical Report: The pediatrician’s role in the diagnosis and
management of autistic spectrum disorders of children,
Pediatrics, 107. Filipek, P.A., et al.
parameter: Screening and diagnosis of autism. Neurology
2000, 55: 468-79. These guidelines are endorsed by the American Academy of Neurology
and the American Academy of Pediatrics.
2 To keep
pediatric professionals informed, First Signs
will follow the development of new
and improved screening tools as they are introduced, tested, and normed on large
populations of children. This information will be published on the First Signs
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