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
2. Conduct routine developmental screening and surveillance

If concerns are raised:
3. Refer to Early Intervention AND to specialist for further developmental evaluation
4. Conduct lead screening
5. Perform formal audiological assessment
6. Conduct autism screening.

If additional concerns are raised:
7. Refer for formal diagnostic testing

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 interventions.

These recommended guidelines are critical to ensuring that young children stay on a healthy developmental path.

Screening Guidelines

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.

2. 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. See 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:

3. 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) inside panels.

4. 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.

5. 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.

6. Autism screening. If a routine developmental screening raises concerns, First Signs 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.

Screening Tools 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:

7. 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 spectrum disorder.

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. Practice 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 Web site.

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