The ABCs of pediatric screening.
Most parents fret over their child’s well-being — it’s natural. We want our kids to have a carefree childhood filled with health and happiness and simple pleasures, like making mud pies on a summer’s day. Then, when they’ve grown, we can beam with pride over their Rhodes scholarship.
Well, since not every child is destined to become a Rhodes Scholar, let’s focus on the healthy and happy part. Just as children are expected to fall within certain guidelines for weight and height as they grow, they are expected to reach milestones related to other physical development, as well as learning and behavior. Screening can help identify kids who appear to be lagging or not developing properly so that intervention can begin as soon as possible.
More pediatricians now consistently screen for developmental delays in early childhood, at least partly thanks to a recent push by the American Academy of Pediatrics (AAP). The AAP’s advocacy is an effort to standardize and refine screening, says Lila H. Monahan, M.D., F.A.A.P., pediatrician with Partners in Pediatrics, affiliated with Southern New Hampshire Medical Center in Nashua. The AAP currently recommends screening at ages 9, 18 and 24 or 30 months, or whenever a parent or pediatrician feels the need for it.
Surveillance vs. screening
Ever notice that your pediatrician spends some time chatting and observing, but not necessarily examining your child, at well-child visits? He or she is probably not engaging in small talk but is gathering clues regarding your child’s health and development. This is known as surveillance, a monitoring of development over time, says Carol L. C. Little, M.D., pediatrician and director of neonatal follow-up at Dartmouth-Hitchcock Medical Center in Lebanon. “It’s what your pediatrician does when he’s asking questions or asks if you have any concerns,” says Little.
Whereas surveillance is something most pediatricians do on an ongoing basis at well-child visits, screening occurs at discrete points in time and allows the pediatrician to look more closely at development, Little says. It is meant to flag — but not necessarily diagnose — potential problems. Pediatricians can choose from a variety of standardized screening tools, which usually are questionnaires that parents answer.
Most of the screening tools that pediatricians use are meant to gauge overall development by comparing it with expected progress and milestones. Screening tools are usually general in nature, except for the AAP’s recommended screen for 18-month-old children, which focuses on autism, Little says. Screening results that are considered “normal” will vary at each testing point in time, based on expected development for children at that age.
Pediatric screening, straightforward though it may seem, can be a complicated undertaking, especially given the fact that it involves children and parents and all the emotional undercurrents that can come into play whenever parents and their babies are concerned. “It’s a huge social context,” Little says.
And screening is not a perfect science, experts say, and can produce faulty results. “You don’t want to identify kids falsely as having problems, and you don’t want to under-identify, but when you’re screening, you’re likely to have some of both,” Little says. Plus, “there is a huge overlap between what is normal and abnormal,” she says, “so that even if you see something early on, you’re not sure what it means always. Early screeners do not necessarily predict later outcome,” she says.
Trust your gut
What is the parents’ role in pediatric developmental screening? Having courage, for starters. Parents should not be afraid to speak up or draw attention to something that worries them. “We’d much rather hear about a concern and then either reassure you or say, ‘Yeah, I’m concerned, too. Let’s come up with a plan,’” Monahan says. Parents should provide honest answers to screening questionnaires and do their best to provide an accurate and thorough family history, as well.
Yet, it’s not uncommon for parents to delay bringing up worries at the pediatrician’s office because friends tell them that the child’s symptom or behavior is just a “boy/girl thing,” or because the child’s grandparent says the child’s father “was like that, too” and turned out fine. “Trust your gut instinct,” Monahan says. “If your gut instinct is saying something’s wrong,” talk to the pediatrician about it.
Luckily, during their child’s earliest years particularly, parents have many opportunities to ask questions or raise concerns, because well-child visits occur frequently. All those appointments also give the pediatrician multiple chances to check the child’s development. “Parents sometimes think those frequent appointments are just for immunizations,” Monahan says. “The immunizations are timed to the visits so that parents don’t have to come in all the time, but there’s so much more going on during the visit than just the immunization.”
Screening can also serve as an educational tool, a springboard that pediatricians use with families to review developmental expectations and broach related topics, Little says. If screening indicates that a child is slow in talking, for example, and the pediatrician is worried that language stimulation might be impoverished in the family, he or she can discuss the screening results with the family and provide some consultation and advice, Little says.
The ultimate goal of developmental screening, however, is to identify problems early so that intervention can begin, because, for many developmental problems, the sooner a child receives help, the better the outcome. “Kids’ brains are very malleable when they’re young,” Monahan says. “The data shows that the earlier you can intervene with early developmental disabilities, the better.”
So, if screening does raise a red flag, the physician can schedule further diagnostic testing to pinpoint the problem. Treatment and intervention can then begin, Little says, as opposed to the likely scenario facing a child whose problem goes undetected, in which he or she remains at risk of developing compounded social, behavioral and learning problems for years.
Parents of a child who does have an identified developmental delay can take comfort in knowing that top-notch help is available, Monahan says. Granite Staters are “really lucky,” she says, because we have so many expert resources nearby, including Dartmouth-Hitchcock, MassGeneral Hospital for Children, Children’s Hospital in Boston and Tufts Medical Center. “We’re in a really good place where we live,” she says. NH
Using MilestonesDuring pediatric developmental screening, a doctor checks to see that a child is developing normally, using standard milestones as a guide. Skills related to movement, language and social relatedness might all be considered, with the physician’s expectations varying depending on the child’s age. For more information, visit the American Academy of Pediatrics at www.aap.org.