Question

• Is it cost-effective to formally screen for developmental and behavioral disabilities in a primary care clinic?

Clinical Bottom Lines

1. Using conventional interviewing techniques, pediatricians only detect ~50% of children with developmental and behavioral disabilities.
   
2. Effective interventions are available. However, the specifics of interventional strategies (e.g. age, techniques, etc.) are still being debated.
   
3. Use of the Ages & Stages Questionnaire (5-10 min) and either the Eyberg Child Behavioral Inventory or the Pediatric Symptom Checklist should enable clinicians to cost-effectively detect >80% of children with disabilities.
   
4. Addressing some issues "in-house" (e.g. ADHD, anxiety, depression) reduces the number of referrals.

Summary of Key Evidence

1. Prevalence
   12 - 16% of American children have developmental or behavioral disorders.¹
   11 - 20% of school-age children could have clinically significant behavior problems.²
2. Detection
   Pediatricians detect only ~50% of children with developmental or behavioral disabilities.³
   In one study, over 90% of referred patients have a diagnosed developmental disability.⁴
3. Intervention
   Disabled persons with high-school diplomas are 40% more likely to be employed, go on to further training, and earn higher wages.⁵
   Early, intense, and sustained intervention produce the greatest and most sustained benefits. Early non-intense intervention does not yield significant long-term benefit.⁶
   Indirect intervention (i.e. training the parents) does not appear to affect long-term outcome.⁶
4. Screening
   Screening tools are available that can be photocopied and filled out by the parents.
   Sensitivity and specificity of these tests are generally >80% and >70%, respectively.
   Using formal screening tools may increase detection by 60%. This may come at the price of increasing the number of referrals to state agencies.

Additional Comments

Citation

1. CA Boyle, P Decoufle, MY Yeargin-Allsoop. Prevalence and health impact of developmental disabilities. Pediatrics 1994; 93:863-865.
   
2. T Stancin, TM Palermo. A review of behavioral screening practices in pediatric settings: do they pass the test? J Dev Behav Pediatr 1997; 18(3):183-94.
   
3. J Lavigne et al. Behavioral and emotional problems among preschool children in pediatric primary care: Prevalence and pediatrician's recognition. Pediatrics 1993; 91:649-55.
   
4. MI Shevell, A Majnemer, P Rosenbaum, M Abrahamowicz. Profile of referrals for early childhood developmental delay to ambulatory subspecialty clinics. J Child Neur 2001; 16(9):645-650.
   
5. M Wagner, J Blackorby, R Cameto, L Newman. What makes a difference? Influences on postschool outcomes of youth with disabilities. Menlo Park, Ca: SRI International, 1993.
   
6. CT Ramey, SL Ramey. Early intervention and early experience. Am Psychol 1998; 53(2):109-20.

Also see:

1. MJ Guralnick. Effectiveness of early intervention for vulnerable children: a developmental perspective. Am J Ment Retard 1998; 102(4):319-45.
   
2. P Hauser-Cram et al. Children with disabilities: a longitudinal study of child development and parent well being. Monogr Soc Res Child Dev 2001; 66(3):1-126.
   
3. D Dobrez et al. Estimating the cost of developmental and behavioral screening of preschool children in general pediatric practice. Pediatrics 2001; 108(4): 913-922.
   
4. J Squires et al. Early detection of developmental problems: Strategies for monitoring young children in the practice setting. J Dev Behav Pediatr 1996; 17(6): 420-427.
   
5. Several articles by Frances Page Glascoe, Ph.D.
   
   

CAT Author: J Randall Finch, MD, PhD

CAT Appraisers: John G. Frohna, MD, MPH

Date appraised: April 22, 2002